Androgenic‐anabolic steroid abuse trend and management: A prospective, cross‐sectional, questionnaire‐based survey

Abstract Background and Aims Androgenic‐anabolic steroid (AAS) abuse is a global health concern, studies revealing an increasing trend of abuse and deleterious effects on reproductive health. Unfortunately, there is no consensus about management pathways due to the lack of specific guidelines. Methods A prospective study, multicentre, online survey, composed of 30 questions, was conducted to investigate the current trend of AAS abuse and the management followed by practitioners from different specialities dealing with this condition. Results A total of 151 respondents were included. The majority were general urologists (68.21%), andrologists (22.51%), and endocrinologists (9.28%). An increasing trend of AAS abuse was noticed by 90.73% of participants mostly in young age populations. Most of AAS abusers were presented with infertility (64.24%) and erectile dysfunction (59.60%), and their investigations showed abnormal semen analysis (77.48%), abnormal hormones (follicle‐stimulating hormone, luteinizing hormone, testosterone, and estradiol) (94.70%), and reduction in testicular size (50.33%). Most of respondents expected: the need of long duration for spontaneous recovery (6–12 months), relapse of AAS abuse in one‐third of patients, less knowledge about the adverse effects (39.74%), and risk of drug dependence (54.30%). Immediate treatment was the most offered plan of management (44.37%) followed by a waiting spontaneous recovery (32.45%), while the remaining would refer the patients to an either endocrinologist or andrologist. The treating physicians did not follow specific guidelines and most of participants (44.44%) reverted to their personal experience in the management. Conclusions Our study revealed an increasing trend of AAS abuse, deleterious effects of AAS use on reproductive health, and lack of consensuses among the treating physicians regarding the management of related adverse effects. Our study could be considered a call to the scientific bodies to have more studies, establish guidelines for management, and to have better awareness of this serious public health concern.

medications used are off-label. [14][15][16] These facts further complicate the management of AAS-abuse-related adverse effects because there is no specific expected duration for spontaneous recovery. There are also no specific recommendations on what type or doses, or duration of medications can be used in the treatment. In addition, the proposed treatment itself could result in further deterioration and adverse effects.
All these shortages are real good proposals for future studies and were the basis of conducting our study. To the best of our knowledge, this is the first survey study ever to explore the current practice of urologists, andrologists, and endocrinologists involving in AAS management and document the prevalence, evaluation methods, and treatment modalities by determining the areas of the agreement and disagreement among the practitioners and to prepare a common guideline or recommendation. This study will be of value to all practitioners in this field and international scientific bodies to address the weak points in the current practice and improve the management pathways.

| MATERIALS AND METHODS
An online survey was conducted to investigate the current trend of AAS abuse, and the management guidelines followed by practitioners from different specialists dealing with this condition (urologists, andrologists, and endocrinologists). It was a prospective, crosssectional, multicentre, observational survey, composed of 30 questions, which aimed to identify the responders background speciality, country, and practice setting (Q1-3), AAS abuse trend, age of abusers, purpose and advice of intake, the source of AAS preuse counselling, duration and frequency of the courses (Q4-9), the most common presentation symptoms, signs and investigations performed (Q10-16), the management guidelines and medications used (Q17-21), AAS users attitude, the current shortcomings in management guidelines, related educational activity and awareness programs (Q22-30).
We used the Google survey tool to formalize the survey. A link of the survey was sent to urologists, andrologists, and endocrinologists through LinkedIn, database emails of Arab Society of Urology, and other social media groups of concerned specialities in different countries. Only the fully attempted survey forms were included.
All statistical analysis was performed using the software STATA version 15.0. Each characteristic was illustrated appropriately. For continuous variables, data were formulated and presented using means ± SD. For categorical data, the number and percentages were used in the data summaries.
The study was approved by the ethical committee of Arab Society of Urology and all surveyors were asked in the first page of the survey to consent for using their data and responses for publication.  Regarding the presenting symptoms, infertility was the most common (64.24%) followed by erectile dysfunction (59.60%) and loss of sexual desire (56.95%). For the evaluation of AAS users, the hormonal profile was the most performed initial investigation (90.07%), followed by semen analysis (72.19%).
More than three-quarters of the participants (77.48%) found abnormal semen parameters of AAS users at presentation, while the remaining (22.52%) claimed it as being normal. On clinical evaluation of the AAS users, testicular size reduction was perceived by half the participants (50.33%), testicular atrophy by 3.97%, and 45.70% noted no change in testicular size, as shown in Table 2.
Regarding the management of AAS-related adverse effects showed that the immediate treatment was the most offered plan of management (44.37%) followed by a waiting for spontaneous recovery (32.45%) and referring the patient to an endocrinologist (13.91%), or an andrologist (9.27%). Spontaneous recovery of sexual symptoms following the termination of AAS use was mostly believed to take 6-12 months (42.38%), followed by 3-6 months (32.45%), more than a year (17.88%), and 1-3 months (  Another important finding is half of respondents in our study noted AAS use dependence in their patients, which is considered another serious negative impact and community concern and was noticed in other studies like Kanayama G study 22 which rated its incidence as 30% in their cohorts. Furthermore, Horwitz et al. 23 concluded that AAS users have an increased risk of dying and significantly more hospital admissions than their nonuser peers.
These remarkable findings raised the public health concerns about endangering the younger population health and warn the concerned authorities to make more rules and policies to contain the abuse of AAS.
Regarding the management of AAS abuse adverse effects, our study revealed no consensus among the practitioners, as 41% offered immediate treatment while 32% preferred waiting for spontaneous recovery. Also, there is no consensus on the type and duration of medications for the treatment of AAS abuse-related infertility or sexual symptoms. The same findings were elicited in other studies [14][15][16][24][25][26]

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
All authors have read and approved the final version of the manuscript (Dr. Manaf Al Hashimi) had full access to all the data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis. Herewith, the authors confirm there are no retracted references. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

TRANSPARENCY STATEMENT
The lead author Manaf Al Hashimi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.